Basic Information
| Provider Information | |||||||||
| NPI: | 1245697754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANCOVICI | ||||||||
| FirstName: | TY | ||||||||
| MiddleName: | THI | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GOVE ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021281920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 GOVE ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021281920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2262113 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.